How do I treat post nasal drip?

Treatment of Post Nasal Drip

First-line treatment for post nasal drip should include saline nasal irrigation and intranasal corticosteroids like fluticasone propionate, with short-term use of first-generation antihistamine/decongestant combinations for symptomatic relief in adults and children over 6 years of age. 1

Understanding Post Nasal Drip

Post nasal drip (PND) refers to the drainage of secretions from the nose or paranasal sinuses into the pharynx. It is now more accurately referred to as Upper Airway Cough Syndrome (UACS) when associated with cough, as it's unclear whether the mechanism of cough is the PND itself or direct irritation of cough receptors in the upper airway. 2

Common symptoms include:

• Sensation of mucus dripping down the throat
• Frequent throat clearing
• Nasal discharge
• Cough (in UACS)

Diagnostic Approach

The diagnosis of PND is primarily clinical as there is no definitive test. Look for:

• Patient-reported sensation of drainage down the throat
• Presence of mucoid or mucopurulent secretions in the nasopharynx/oropharynx
• "Cobblestoning" of the posterior pharyngeal mucosa

Consider underlying causes:

• Allergic rhinitis
• Perennial nonallergic rhinitis
• Postinfectious rhinitis
• Bacterial sinusitis
• Anatomic abnormalities
• Physical/chemical irritants
• Rhinitis medicamentosa
• Gastroesophageal reflux disease (may mimic PND)

Treatment Algorithm

Step 1: First-line Treatments

• Saline nasal irrigation: Improves mucous clearance, enhances ciliary activity, and removes irritants 1
• Intranasal corticosteroids (e.g., fluticasone propionate): May provide relief starting from the first day but takes several days to reach full effectiveness 3
  • Adults and children ≥12 years: 2 sprays in each nostril once daily for week 1, then 1-2 sprays in each nostril once daily as needed for up to 6 months
  • Children 4-11 years: 1 spray in each nostril once daily for up to 2 months per year (monitor growth)

Step 2: Symptomatic Relief

• First-generation antihistamine/decongestant combinations: For short-term use (maximum 3 weeks) in patients over 6 years 1

  • Examples: dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate
  • Caution: Can cause drowsiness, urinary retention, and increased blood pressure

• Topical decongestants: Limit to 5-7 days maximum to prevent rhinitis medicamentosa 1

Step 3: For Specific Underlying Causes

• Allergic rhinitis: Add non-sedating antihistamines and continue intranasal corticosteroids 1
• Bacterial infection: Consider antibiotics if thick discharge persists >4 weeks; reassess after 2 weeks of treatment 1
• Rhinorrhea-predominant symptoms: Consider ipratropium bromide nasal spray 1
• Refractory cases: Consider leukotriene receptor antagonists as additional treatment 1

Important Considerations and Precautions

• If symptoms aren't improving after one week of treatment, consult a doctor as you may have an infection 3
• Fluticasone propionate does not cause rebound effects like topical decongestants and can be used for longer periods 3
• Over-the-counter cough and cold medications are not recommended for children under 6 years due to potential toxicity and lack of efficacy 1
• For persistent symptoms (>4 weeks despite treatment), consider referral to an otolaryngologist, especially with warning signs like unilateral symptoms or bloody discharge 1
• Recent research suggests oral gargling with normal saline may be beneficial for patients with PND without cough 4
• In refractory cases, posterior nasal nerve ablation has shown promise, with 72.5% of patients reporting at least 30% improvement in PND symptoms 5

Monitoring and Follow-up

• Monitor for side effects of medications:
  • Intranasal corticosteroids: Minor nosebleeds, nasal irritation
  • Antihistamines/decongestants: Sedation, urinary retention, hypertension, tachycardia
• If symptoms persist despite appropriate treatment for 4 weeks, consider further investigations for underlying conditions like chronic sinusitis, GERD, or allergic rhinitis 1
• For children 4-11 years using intranasal corticosteroids, monitor growth if used for longer than 2 months per year 3

Remember that empiric treatment response is both diagnostic and therapeutic for PND, as there is no definitive test to confirm the diagnosis 2.